Abstract

AIMS AND METHOD

To provide a composite view of the impact of indefinite detention under the
Anti-Terrorism Crime and Security Act 2001. Until recently, a number of
detainees had been detained under this legislation since December 2001. The
impact of this on eight detainees and three of their spouses is examined
through qualitative analysis of 48 reports and documents compiled by 11
psychiatrists and 1 psychologist.

RESULTS

Detention has had a severe adverse impact on the mental health of all
detainees and the spouses interviewed. All were clinically depressed and a
number had post-traumatic stress disorder. The indefinite nature of detention
was a major factor in their deterioration.

CLINICAL IMPLICATIONS

The use of indefinite detention without trial has severe adverse
consequences that may pose insurmountable problems for the prison healthcare
system.

From December 2001 until March 2005 a number of foreign nationals were
detained indefinitely under the Anti-Terrorism Crime and Security Act 2001 on
the grounds that they were a threat to national security. This was a unique
situation. Previous published work on detention has been in relation to
regimes which use torture during the process of detention. The closest
analogue to the recent situation is the position of asylum seekers in
detention awaiting immigration decisions, where a number of studies have
highlighted the damaging impact that detention may have.

The Victorian Foundation for Survivors of Torture
(1998) in Australia found high
rates of mental illness in relation to detention of 17 East Timorese. They
found that all had post-traumatic stress disorder (PTSD), 94% had depression
and 65% severe anxiety. Clinically significant suicidal ideation was also
reported. In a further group of 46 Cambodian asylum seekers detained for up to
2 years Steel et al
(2004) found that 62% had PTSD,
all were clinically depressed and 94% had clinical anxiety.

Silove et al (1998)
surveyed 25 detained Tamil asylum seekers held in Victoria, Australia.
Compared with community-based Tamil asylum seekers, detainees reported a
greater level of trauma exposure, were more depressed, suicidal, and suffered
more extreme post-traumatic and physical symptoms. Past trauma exposure did
not entirely account for symptom differences across the groups, suggesting
that detention was a cause of mental health problems among detainees.

In the UK, Bracken & Gorst-Unsworth
(1991) carried out a file audit
of ten detained asylum seekers, of whom six had documented physical evidence
of torture. All reported depressed mood, appetite loss and somatic symptoms.
Suicidal ideation was present in four, with two having a history of serious
suicide attempts. This was similar to another UK study by Pourgourides et
al (1995) of 15 detained
asylum seekers. The majority gave histories of traumatic experience and
presented with high levels of depressive and post-traumatic stress symptoms,
profound despair and suicidal ideation. There were serious attempts at
self-harm.

Sultan (2001), a physician
who himself was held in detention, described the situation for 36 detainees
held for over 12 months in detention in Australia. Thirty-three had clear
evidence of severe depression, the remaining three experiencing mild
depressive symptoms. Six developed clear psychotic symptoms and five had
strong aggressive impulses and persistently self-harmed. Most displayed little
if any of those symptoms prior to their detention. Sultan &
O’Sullivan (2001)
described deteriorating psychological well-being in 33 people held for over 9
months, with the immigration process being implicated in the deterioration. Of
these, 85% were depressed and 32 out of 33 displayed significant symptoms
during their detention.

Keller et al (2003)
in a survey of detainees in the USA found that 77% had clinically significant
symptoms of anxiety, 86% depression and 50% PTSD. At follow-up they found that
those released had a marked reduction in psychological symptoms but those
still detained had deteriorated. There was a strong association between level
of symptoms and length of detention.

These studies suggest that detention per se is a strong factor in causing
deterioration in mental health over and above any mental health problems that
are the result of pre-detention trauma. Although there are a number of
parallels, immigration detainees always have hope of an end-point in terms of
an immigration tribunal or court decision, something the Belmarsh detainees
did not have during their imprisonment.

Method

This study concerns eight detainees under the 2001 Anti-Terrorism Crime and
Security Act. It originated from a series of reports prepared at the request
of solicitors and is based on the independent reports of 11 consultant
psychiatrists and 1 consultant clinical psychologist. Concern grew with the
realisation that there were a number of common features in the independent
reports.

All detainees were seen on more than one occasion and by more than one
clinician. In addition, reports by physicians, occupational therapists and
social workers also informed the process. In total, 48 reports and documents
were included in this analysis. The documents were subject to qualitative
analysis, but only findings which were corroborated by more than one clinician
were reported. The results of the analysis were circulated to all the authors
for comments and verification and following a number of iterations were
developed into the final report (Robbins
et al, 2004). This paper represents an abbreviated
version of that report.

Results

Pre-migration factors

Six of the detainees were Algerian, one was Tunisian and one from Gaza. All
were literate and educated, in some cases to university level. Four had a
previous psychiatric history prior to their arrest and three had a clear
family history of mental health problems. Several had serious physical health
problems, including bilateral traumatic amputation of arms, the consequences
of childhood polio, lower back injuries, etc., which interact with and
influence mental state. Three had experienced previous detention and torture,
but all had been in situations of political instability and unrest. All were
devout Muslims and originate from countries where mental illness is highly
stigmatised.

Presentation and progress following detention

All the detainees were found to have significant levels of clinical
depression and anxiety and showed deterioration over time. In a number of
cases there was also a diagnosis of PTSD. This was in relation to
pre-migration events, their arrest and imprisonment or both working
synergistically. There was a high level of suicidal ideation and attempts at
self-harm. Deterioration in mood state was clearly linked to a sense of
helplessness and hopelessness, which is an integral factor in indefinite
detention. Concern with regard to their wives’ mental state was
exacerbating the mental health problems of some detainees.

On a number of occasions, detainees’ behaviour had been interpreted
by prison staff as manipulative, particularly where there was a failure to
cooperate with the healthcare regimes. There is clearly a failure to perceive
that this behaviour could reflect a deterioration in mental state. Where there
were complex health needs, as for instance in the case of a polio survivor and
amputee, these needs were not being adequately met within the prison
system.

As their mood deteriorated a number developed significant psychotic
symptoms which were not present prior to detention. In one detainee who was
released on stringent conditions of house arrest, the psychotic symptoms
receded within a short period following release, but the underlying depressive
features were more slow to respond. In another case, although transfer to
Broadmoor produced an initial improvement in clinical state, this has since
fluctuated.

There is a strong consensus among the clinicians that indefinite detention
per se is directly linked to deterioration in mental health and that
fluctuations in mental state are related to the prison regime itself and to
the vagaries of the appeal system. While indefinite detention continues there
is agreement that it is highly unlikely that the prison healthcare team will
be able to combat the deterioration in mental health. This is not a criticism
of the prison psychiatric inreach team, rather it is an acknowledgement of the
extent of the damage which indefinite detention without trial gives rise
to.

Impact of detention on spouses

Three wives were seen by two clinicians whose reports show a high degree of
congruence. There is clearly a high burden of stress imposed on wives and this
is contributing negatively to their mental state. Whereas having a husband in
prison may be seen as stressful for many women, their problems are seen as
over and above what would normally be expected.

All three women were showing signs of clinical depression, with one showing
signs of PTSD and another a phobic anxiety state. Their symptoms were related
directly to the incarceration of their husbands and its indefinite nature,
with their isolation compounding their difficulties. Their state fluctuated in
relation to their husbands’ problems and is unlikely to improve in the
near future.

House of Lords decision

In December 2004, the Appellate Committee of the House of Lords
(2004) delivered a judgment
that found indefinite detention without trial to be contrary to fundamental
legal principles. Lord Hoffmann one of the judges involved stated

‘This is one of the most important cases which the House has had to
decide in recent years. It calls into question the very existence of an
ancient liberty of which this country has until now been very proud: freedom
from arbitrary arrest and detention. The power which the Home Secretary wishes
to uphold is a power to detain people indefinitely without trial or charge.
Nothing could be more antithetical to the instincts and traditions of the
people of the United Kingdom’.

The detainees were released in March 2005, but only after further powers
were introduced in the form of control orders in the Prevention of Terrorism
Act 2005.

Discussion

The detainees originated from countries where mental illness is highly
stigmatised. For devout Muslims there is a direct prohibition against suicide,
making the number who have attempted or are considering suicide very
significant. All the detainees had serious mental health problems which were
the direct result of, or were seriously exacerbated by, the indefinite nature
of the detention. The mental health problems predominantly took the form of
major depressive disorder and anxiety. A number of detainees developed
psychotic symptoms as they deteriorated. Some experienced PTSD, as a result of
their pre-migration trauma, their arrest and imprisonment or the interaction
between the two.

Continued deterioration in their mental health was also affected by the
nature of, and their mistrust in, the prison regime and the appeals process,
as well as the underlying and central factor of the indefinite nature of
detention. The prison healthcare system was unable to meet their health needs
adequately. This is not a criticism of the healthcare system but is rather an
acknowledgement of the causative role of the indefinite nature of the
detention in the generation of mental illness. There was, however, a failure
by prison staff to perceive self-harm and distressed behaviour as part of the
clinical condition rather than being purely manipulative.

The mental health problems of the detainees did not resolve while they were
maintained in detention. The detainees’ problems were remarkably similar
to those described in relation to immigration detention. There too, there are
high levels of depression and anxiety, with the length of time in detention
relating directly to the severity of symptoms. The indefinite nature of
detention per se is acknowledged as causal in relation to psychiatric
problems.

There is also evidence that this had a severe adverse effect on the wives
of the men in detention. Their symptoms were related to the incarceration of
their husbands and the indefinite nature of the detention. Their isolation
exacerbated the impact of their husbands’ detention and there was little
improvement while their husbands were detained. The condition of the wives
also had a corresponding effect on their husbands’ mental state.

In conclusion, there is evidence from repeated clinical interviews carried
out by expert clinicians that indefinite detention has a damaging impact on
mental health. All of the detainees experienced major depressive disorder and
anxiety, with some experiencing PTSD. Their healthcare needs could not be
adequately met while they remained in detention. There was also a major impact
on the wives of detainees. The problems of the current detainees are similar
to those described in the literature for prolonged immigration detention with
the caveat that in the case of immigration detainees there is always an
end-point.

The process of indefinite detention has been deemed to be unlawful and the
men have been released under control order restrictions but are still
suffering adverse consequences of their detention. In come cases, this is
being further aggravated by the restrictions inherent in the control
orders.

VICTORIAN FOUNDATION FOR SURVIVORS OF TORTURE (1998)
The East Timorese: clinical and social assessments ofapplicants for asylum. In
The Mental Health and Well Being of Onshore Asylum Seekers in
Australia (eds D. Silove & Z. Steel), pp. 23
-27. Sydney: University of New South Wales Research
and Teaching Unit.